MEDICARE: MALHOTRA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-052517	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01633163	OTHER	IL	BCBSIL GROUP #

General Provider Information

NPI Number	:	1225083983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALHOTRA LLC

Provider Business Mailing Address
First Line	:	PO BOX 970
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-0970
Country	:	US
Telephone Number	:	708-747-5850
Fax Number	:	708-747-9991

Provider Business Practice Location Address
First Line	:	16750 80TH AVE
Second Line	:	SUITE E
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-3173
Country	:	US
Telephone Number	:	708-633-9000
Fax Number	:	708-633-9016

Authorized Official
Title or Position	:	OWNER
Name	:	SHASHI K MALHOTRA
Credential	:	M.D.
Telephone Number	:	708-633-9000

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	08/18/2008

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